obesitysurgerycriteriachecklist

Approval Criteria Checklist for Obesity Surgery* A reference guide of standard obesity surgery coverage criteria

to assist you in selecting a benefit design plan that will meet your company’s needs

DSL# 10-0179 ©2010 All rights reserved EREM027 *Compiled from multiple sources. See Reference List.

Candidate Qualifications for Surgery

Suggested Additional Candidate Qualifications for Surgery

Documentation that other methods of weight loss have been tried unsuccessfully (e.g., changes in eating, behavior, increased physical activity and/or drug therapy)

Documentation that performing daily routine activities (e.g., work-related & family functions) are not possible & quality of life is seriously impaired due to severity of obesity

Documentation of a formal psychological evaluation demonstrating the patient is a sound candidate for bariatric surgery & is able to adhere to post surgical behavior management requirements

Documentation of 3 continuous months of compliance with medically supervised, non-surgical weight reduction methods by PCP or bariatric surgeon

Documentation of a Pre-Surgery Evaluation: evaluations may vary based on patient needs & surgeon preference but should at least include the following:

Medical (including clearance from primary care physician)

Surgery (by bariatric surgeon)

Cardiology (in selected patients to uncover potential heart disease & to determine treatment as necessary)

Pulmonary (including a pulmonary function test & when indicated, a sleep apnea test)

Psychological or psychiatric

Endocrinology

Nutrition

Documentation of participation in a comprehensive Weight Management Program: Must attend & comply with all outlined activities & visits as established by the bariatric program. The Weight Management Program should Include, at Pre & Post Surgery, these components: ____ Nutrition Education ____ Surgeon & RN Visits

____ Personalized Exercise Program ____ Comprehensive Lab Work-ups

____ Psychological Evaluation ____ Bariatric Program Coordinator ____ Support Groups ____ Behavior Management Program

____ Appropriate Diet Supplementation ____ Family & Social Support System

____ Surgery Education

Super Obese BMI ≥50

Extreme Obesity / Class III Obesity BMI ≥40

Obese/Class II Obesity BMI ≥35 – 39.9 with serious, co-morbid, medical conditions

Hypertension

Type II Diabetes Mellitus

Dyslipidemia

Musculoskeletal, neurological or body size problems precluding or severely impairing qual-ity of life (employment, family function or ambulation)

Life-threatening Cardiopulmonary Problems (sleep apnea, obesity-hypoventilations syn-drome or obesity-related cardiomyopathy)

Coronary Artery Disease

Obesity-Related Cardiomyopathy

Provider Qualifications



Recognized COE (Center of Excellence/Center of Distinction) facility and/or surgeon practice by either the Surgical Review Corporation (SRC), the American College of Surgeons (ACS), Medicare & Medicaid Services (CMS) or a Health Plan, such as Aetna, BCBS, CIGNA, UnitedHealthcare.

Rural Area Exception – See “Clarification Points” Section

STANDARD PROCEDURES

Open or Laparoscopic Roux-en-Y (gastric bypass)

LAGB (Laparoscopic Adjustable Gastric Band)

VBG (Vertical Banded Gastroplasty)

BPD (Biliopancreatic Diversion)

LSG (Laparoscopic Sleeve Gastrectomy)

INVESTIGATIONAL

PROCEDURES

Mini Gastric Bypass

Gastric Balloon

Surgical Procedures

Benefit Design Options Limit coverage to Centers of Excellence facilities & surgeons as defined by CMS

(Medicare & Medicaid Services) the SRC, the ACS or health plan

Provide different patient co-insurance levels based on selecting COE facility or non-COE facility

Consider employment tenure for bariatric surgery benefit to be accessed

Tie surgical benefit & COE program requirements in with company sponsored wellness or obesity management programs

Provide a Post-Surgery Incentive Strategy Some examples include:

Set up criteria for post-surgery maintenance & program adherence. With achievement

of “x number” of met criteria patient/employee may qualify for paid or partially paid post-

bariatric plastic surgery.

Set up criteria for post surgery maintenance & program adherence. With achievement

of “x number” of met criteria patient/employee may receive reimbursement dollars back

into their HSA account.


Clarification Points

Other areas of discussion related to benefits design are listed below.

However, there is not sufficient clinical documentation to make a

recommendation. For each topic, a reference is included to assist with

decision-making.

Repeat Surgery To include revisions, repeat surgeries and conversion surgeries https://secure.preferredone.com/Shared/MedicalPolicy/MC_H003.pdf

California Association of Health Plans Consensus Statement; or National Health Plan Medical Policies (cited below)

A. Conversion to another surgical procedure – including all of the following 1-3: 1. Failure to respond to initial gastric bypass

2. Original surgery was at least 2 years prior to repeat procedure 3. Documentation that patient has been enrolled in & compliant with the previous postoperative program

B. Revision of obesity surgery due to documented surgical complication from the pri-mary procedure that has not responded to medical treatment – including, but not limited to, one of the following:

1. Obstruction

2. Stricture

3. Dilatation of gastric pouch (only if procedure was successful in inducing weight loss prior to pouch dilatation) 4. Stoma dilation or stenosis

5. Stoma ulcer 6. Malnutrition

C. Take down (reversal) of obesity surgery (only if documented complication present)

Note: All requests for repeat obesity surgery for staple line breakdown must be referred for physician review.



Rural Area COE Exception

It has been suggested that in rural areas where the volume requirements cannot be made that the facility must be COE provisional status level with the SRC or Level II status with the ACS.

http://bbthor.bcbsnd.com/Bulletins/Blue_Cross_Blue_Shield_ND_Medical_Policy/Bariatric_Surgery.htm


https://secure.preferredone.com/Shared/MedicalPolicy/MC_H003.pdf

COE REQUIREMENTS COE standard requirements vary among credentialing bodies but all address:

Surgical Volume & Training: Usually a minimum of 125 surgeries per year/facility

Surgeon performed at least 125 total bariatric cases lifetime with at least 50 cases performed in the preceding 12-month period

Processes in place for additional training & training of new surgeons brought into practice

Medical Director: Physician Medical Director for bariatric surgery who participates in the relevant deci-

sion-making administrative meetings of the institution

Trained Bariatric Staff & Program Extenders: Utilization of a designated nurse or physician extender who are dedicated to serving

bariatric surgical patients & who are involved in the continuing education & care of bariatric patients

Organized & supervised support groups for all patients who have undergone bariat-ric surgery at the institution

Program dedicated to a long-term patient follow-up goal of at least 75% at five years for bariatric procedures with a monitoring & tracking system for outcomes

Equipment: For the care of bariatric surgical patients including furniture, wheel chairs, operating

room tables, beds, radiologic capabilities, surgical instruments & other facilities suitable for morbidly obese patients

Care Pathways: Facilitate the standardization of perioperative care for the relevant procedure

Data Collection: Collect & report outcomes for surgeon & facility

Clarification Points




References

1 Does Preoperative Weight Loss Predict Success with Laparoscopic Roux-en-Y Gastric Bypass. Bariatric Times, April 2007

2 Oregon Health Resources Commission MedTAP Report June 2007

3 Sjostrom L, et.al. Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. NEJM 357 (8) August 23, 2007

4 Adams TD, et al. Long Term Mortality after Gastric Bypass Surgery. NEJM 357 (8) August 23, 2007

5 Bray GA. The Missing Link – Lose Weight, Live Longer. NEJM 357 (8) August 23, 2007

6 http://www.lapsurgery.com/BARIATRIC%20SURGERY/ASBS.htm

7 CMS National Coverage Decision: http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=160 [online]

8 CMS Centers of Excellence List: www.cms.hhs.gov/center/coverage.asp [online]

9 National Institute of Health Consensus Statement on Bariatric Surgery: http://consensus.nih.gov/1991/1991GISurgeryObesity084PDF.pdf [online]

10 http://www.anthem.com/medicalguidelines/va/f5/s10/t2/pw_037637.pdf [online]

11 https://www.unitedhealthcareonline.com/b2c/cmaIndexResult.do?channelId=016228193392b010VgnVCM100000c520720a____&htmlFilePath=/ccmcontent/ProviderII/UHC/enUS/Assets/ProviderStaticFiles/ProviderStaticFilesHtml/MedicalPolicies/Bariatric_Surgery.htm [online]

12 http://www.humana.com/providers/tools/provider_tools/clinical_healthcare.asp [online]

13 http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/medical/mm_0051_coveragepositioncriteria_bariatric_surgery.pdf [online]

14 http://www.aetna.com/cpb/medical/data/100_199/0157.html [online]

15 Bradley DW; Sharma C, Bal K. Centers of Excellence in Bariatric Surgery: Design, Implementa-tion and One-Year Outcomes. Surgery for Obesity and Related Diseases, 2 (2006) 513-517

16 California Association of Health Plans: The Consensus Guidelines on Bariatric Surgery: CAHP Obesity Initiative Workgroup. June 2006

17 http://bbthor.bcbsnd.com/Bulletins/Blue_Cross_Blue_Shield_ND_Medical_Policy/Bariatric_Surgery.htm [online]

18 https://secure.preferredone.com/Shared/MedicalPolicy/MC_H003.pdf [online]

19 https://secure.preferredone.com/Shared/MedicalPolicy/MC_H003.pdf [online]




http://www.lapsurgery.com/BARIATRIC%20SURGERY/ASBS.htm

http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=160

http://www.cms.hhs.gov/center/coverage.asp

http://consensus.nih.gov/1991/1991GISurgeryObesity084PDF.pdf

http://consensus.nih.gov/1991/1991GISurgeryObesity084PDF.pdf

http://www.anthem.com/medicalguidelines/va/f5/s10/t2/pw_037637.pdf

https://www.unitedhealthcareonline.com/b2c/cmaIndexResult.do?channelId=016228193392b010VgnVCM100000c520720a____&htmlFilePath=/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesHtml/MedicalPolicies/Bariatric_Surgery.htm




http://www.humana.com/providers/tools/provider_tools/clinical_healthcare.asp

http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/medical/mm_0051_coveragepositioncriteria_bariatric_surgery.pdf

http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/medical/mm_0051_coveragepositioncriteria_bariatric_surgery.pdf

http://www.aetna.com/cpb/medical/data/100_199/0157.html

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